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Serotypes of pneumococci causing severe infections in Australia: concordance with united states pneumococcal vaccine types
ABSTRACTS OF ANNUAL MEETING
1979 295
synergistically to lower bactericidal concentrations these drugs could have a wide clinical application. Six strains of Proi,idencitr stuurti were isolated from paraplegics with urinary tract infection. When tested separately the M ICs and MBCs of cefuroxime were 64 and 512 mg I respectively. and of ticarcillin 2 and 512 nig'l. However. the organisms were inhibited by cefuroxime 1 mg;l with ticarcillin 4 mg!l. and killed by cefuroxinie 2 mg!l and ticarcillin 4 mg,l. The patients were treated intramuscularly with ticarcillin 1.5 g b.d. and cefuroxime 750 nig i n the morning. and I; h after the morning combination the serum was bactericidal t o the Proi~i(/eticioat dilutions of 1 in 4 to I i n 16. and the organisms were eradicated. Cefuroxime and ticarcillin have been found t o act synergistically also against some strains of K / c ~ / ~ s i c ~ / / ~ r , Enrerohacter, Acinrtohacrcv und Strep. ,/iriwr/is.The MIC of cefuroxinie for Strep. fuecrr1i.s can be mis-read if the the MIC of cefuroxinie wiib inoculuni is too small. Repeated studies showed that in 50 isolates of Strrp. fuc~ccr/i.~ 356 mgll for 12 strains, 512 mg,l for another 31 strains, and 1024 n1g.l for the other 5 strains. Although 87 of 100 strains o1'Strep. fuecu1i.s were inhibited by ticarcillin 32 mg.1. the MBC was usually 512 ing:l. At a concentration of cefuroxime of 16 mg I none of 300 strains of E. w l i were resistant to cefuroxinie. and of 132 strains of Kkehsielku only 3 were resistant. hhereas 6 were resistant to cefoxitin. Of56 strains o f Ent~~oh(1ctr~r47 werc sensitive to cefuroxime but only 6 to cefoxitin. Cefuroxinie is also more active than cefoxitin against - I t . i t i r t o h t i ( ~ r c r . 15 of 27 strains being sensitive, but is less active than cefoxitin against indole-positive Proreu., specisa. C'itrohrrr tci' and Serrutiu. THE CLINICAL USEFULNESS OF TICARCILLIN IN PATIENTS WITH RENAL DYSFUNCTION AND INTRAMUSCULARLY TO TREAT URINARY TRACT INFECTIONS
C. S. GOODWIN, W. E. S. HAKPFR & J. E m D ~ ~ p u r r r ~ or 7f rMit.rohiolo~q~~, R o p l Potlr H o s p i i d Septicaemia in patients with a high serum creatinine is difticult to treat effectively with gentamicin or tobramycin because during the slou excretion period relatively inadequate blood and tissue concentrations of the aminoglycoside usually fail to control the septicaemia. In such patients a more effective regimen of treatment is ii newer cephalosporin or cephamycin combined with tlcarcillin. This combination covers nearly all bacteria because ticarcillin is active against organisms which are not killed by cefuroxime or cefamandole- P.seudnn7onrr.sUWU,gi/.l(J.\t/, Sff'?/JtOCOCCLLS ./urca/is, and Buclc~roirkr~. Ticarcillin is not active against Klchsicllu. or Entrrohucrcv hut these organisms are nearly all killed by cefuroxime or cefamandole. Of 100 strains of Sire/>.fur~culis87 were Inhibited b) ticarcillin 32 mg,l and the remaining strains by 64 ing I. After intravenous injection of 6 g tiearcillin blood concentrations were 200400 mgl, and after 3 g 100-200 mg 1. One patient with faecal peritonitis and a high serum creatinine remained febrile for 3 wk during treatment with gentamicin, ampicillin. and Iincomycin. and K / ~ I ~ ; L , / / U was isolated from his abdominal drain. After treatment with cefuroxirne 1500 mg b.d. and ticarcillin 6 g b.d. he rapidly became afebrile and his drainage fluid became sterile. After 2 wk the dose of cefuroxime was reduced io 750 mg b.d. and ticarcillin to 3 g b.d. Such an antibiotic regimen avoids the use of lincomycin or clindamycin. A n old lady with two collections of pus in the abdomen was unsuccessfully treated with oral metro:iidazole and gentamicin or tobramyciii because her high serum creatinine allowed only one dose of the aminoglycoside per da!, After cefoxitin and ticarcillin she rapidly improved and went to surgery. I n 12 paraplegic patients urinary tract infection due to P.~c~~rcionzon~r.s in 12 patients and Provir/cwc.icr sturrrti In 2 patients was cured with ticarcillin 1 g thrice daily. but relapse occurred in 2 patients with abnormal urinary tracts. 111 the urine ofthese patients the peak concentration of ticarcillin was 630-4200 mg:l and the trough concentration was 150-1 500 mgjl. Ticarcillin can produce useful therapeutic concentrations in the cerebrospinal Iluid. A patient with meningitis aftcr a skull fracture failed to respond to chloramphenicol and gentamicin but rapidly became afebrile and clinicall) improved after high doses of ticarcillin and cloxacillin: 7 11 after 6 g ticarcillin intravenously the cerebrospinal fuid still contained 25 mg;l.
SEROTYPES OF PNEUMOCOCCI CAUSING SEVERE INFECTIONS IN AUSTRALIA: CONCORDANCE WITH UNITED STATES PNEUMOCOCCAL VACCINE TYPES
D. HANSMAN M i c r o h i o l o ~Depurtriivnr ,~~ , AcL*Iuirle Children :\ Hospirul A polyvalent pneumococcal polysaccharide vaccine (Pneumovax, Merck, Sharp & Dohnie) i s now licensed l o r ~ise in the United States and Canada. This 14-valent vaccine includes types 1 3. 4. 6-9. 12. 14. 18. 19. 23 and 25. An application to license the vaccine for administration in Australia has been made recently. I t is therefore important to
296
ROYAL COLLEGE OF PATHOLOGISTS OF AUSTRALIA
Pathology (l980), 12. April
know the ‘cover’ of the vaccine relative to the scrotypes of pneumococci causing infections in Australia, and especially in cases of life-threatening infection, namely bacteraemic pneumonia and meningitis. For the 5-yr period, 1974 through 1978. we have analysed the serotypes of pneumococci isolated from blood cultures and specimens of cerebrospinal fluid. from patients in Adelaide, Melbourne and Sydney. In order of frequency. the 10 predominant pneumococcal types encountered among 268 isolates were types 14,9,3 =4, 19,6. I , 18.7 and 23. in that order. Type 14 was predominant amongst isolates from children and type 9 amongst isolates from adults. All of these types were represented in the vaccine, which also includes types 2, 8, 12 and 25. The 14 vaccine types comprised 79.80, of our isolates. Pneumococci of types 2, 12 and 25 were uncommon and together formed only 0.7:,; of the total. Ifa vaccine is to be prepared especially for use in Australia, pneumococcal types 2, I2 and 25 could be omitted and replaced with types 1 I , 22 and 33: cover would then be increased by 9.3‘;” to 89.1‘;” of the types encountered in this study.
ELECTRON MICROSCOPY OF SKIN AND PERIPHERAL BLOOD LYMPHOCYTES IN THE DIAGNOSIS OF EARLY INFANTILE (SANTAVUORI) NEURONAL CEROID LlPOFUSClNOSlS
M . E. HAYNES,R. F. CARTER, J. I. MANSON& E. F. ROBERTSOWDepurtmmrs ofHisroparho1og.l~. Neurologj und Clzoiiicul Palhalog)>.Arleltide Children :r Hospilal The classification and diagnostic histopathological features of the various types of neuronal ceroid lipofuscinosis (Batten’s disease) will be described briefly. An account will then be given of 2 siblings with the early infantile (Santavuori) type in whom the diagnosis was made by electron microscopy of skin biopsies and peripheral blood lymphocytes. In both patients characteristic osmiophilic inclusion bodies were found in various cells in the skin and in lymphocytes. In one patient lymphocyte inclusions were detected before the onset ofany symptoms a s a result of a family study. This indicates the possibility of screening lymphocytes of siblings of affected patients with a view to early detection of the disorder. Antenatal diagnosis by electron microscopy of foetal lymphocytes may also be possible if the inclusions develop early enough in foetal life. As studies to determine this do not appear to have been done, every opportunity should be taken to examine material from foetuses at risk for the discase.
AN AUTOMATIC DATA HANDLING SYSTEM FOR HAEMATOLOGY
J. M. JACKSON. R. E. DAVIS & D. J . NICOL Departnzenf qf Haemarology. Royal Perth Hospital A successful system needs to be simple to operate, attractive to staff at all levels, offer an improvement in the service to users and be economical in reducing the rate of staff expansion. The system described here is operative in a large teaching hospital. The system uses a Control Data Cyber 171 main frame computer which serves several hospitals. This hospital is linked to themain framecomputer via two Digital Equipment Corporation P D P 1 1 concentrators. At the reception desk, test requests are registered using a VDU keyboard. Patient’s identification and location information is automatically available from the medical records patient master index system thereby reducing to a minimum the amount of keyboard entry required. Each sample is given a 3 digit day number and a 2 digit test code; it is then passed to the laboratory. Computer generated worksheets are used to record results of non-automated tests. Results from worksheets are entered through a VDU terminal in batches. A printer produces all blood film labels complete with patient identification and test code. Samples are processed by a Coulter S-Plus which is interfaced with a Hewlett Packard 9835A mini-computer. Results from the Coulter appear on the mini-computer’s screen, they are transferred to tape cartridge and then transmitted to the Cyber in batches. The mini-computer provides a running statistical analysis of results as required for quality control. Differential leucocyte counts are entered through VDU keyboards located next to each of 4 microscopes. Film comments are entered using a simple alpha numeric code. The patient’s cumulative record is available through the VDU. Reports are printed in batches as required using preprinted stationery, all codes being translated to text at the time of printing. Cumulative patient’s records are stored on disc file for 9 mth and are available through any of the department’s VDU’s on demand. When a patient’s file has been inactive for 9 mth it is transferred to microfiche which is stored in the laboratory. Backup of the main rrame computer is provided by a second Cyber. This system is used to process 350-400 samples daily and has the capacity to handle considerably more with only minor modifications. Using this system all results are available on the same day as specimen receipt.
1979 295
synergistically to lower bactericidal concentrations these drugs could have a wide clinical application. Six strains of Proi,idencitr stuurti were isolated from paraplegics with urinary tract infection. When tested separately the M ICs and MBCs of cefuroxime were 64 and 512 mg I respectively. and of ticarcillin 2 and 512 nig'l. However. the organisms were inhibited by cefuroxime 1 mg;l with ticarcillin 4 mg!l. and killed by cefuroxinie 2 mg!l and ticarcillin 4 mg,l. The patients were treated intramuscularly with ticarcillin 1.5 g b.d. and cefuroxime 750 nig i n the morning. and I; h after the morning combination the serum was bactericidal t o the Proi~i(/eticioat dilutions of 1 in 4 to I i n 16. and the organisms were eradicated. Cefuroxime and ticarcillin have been found t o act synergistically also against some strains of K / c ~ / ~ s i c ~ / / ~ r , Enrerohacter, Acinrtohacrcv und Strep. ,/iriwr/is.The MIC of cefuroxinie for Strep. fuecrr1i.s can be mis-read if the the MIC of cefuroxinie wiib inoculuni is too small. Repeated studies showed that in 50 isolates of Strrp. fuc~ccr/i.~ 356 mgll for 12 strains, 512 mg,l for another 31 strains, and 1024 n1g.l for the other 5 strains. Although 87 of 100 strains o1'Strep. fuecu1i.s were inhibited by ticarcillin 32 mg.1. the MBC was usually 512 ing:l. At a concentration of cefuroxime of 16 mg I none of 300 strains of E. w l i were resistant to cefuroxinie. and of 132 strains of Kkehsielku only 3 were resistant. hhereas 6 were resistant to cefoxitin. Of56 strains o f Ent~~oh(1ctr~r47 werc sensitive to cefuroxime but only 6 to cefoxitin. Cefuroxinie is also more active than cefoxitin against - I t . i t i r t o h t i ( ~ r c r . 15 of 27 strains being sensitive, but is less active than cefoxitin against indole-positive Proreu., specisa. C'itrohrrr tci' and Serrutiu. THE CLINICAL USEFULNESS OF TICARCILLIN IN PATIENTS WITH RENAL DYSFUNCTION AND INTRAMUSCULARLY TO TREAT URINARY TRACT INFECTIONS
C. S. GOODWIN, W. E. S. HAKPFR & J. E m D ~ ~ p u r r r ~ or 7f rMit.rohiolo~q~~, R o p l Potlr H o s p i i d Septicaemia in patients with a high serum creatinine is difticult to treat effectively with gentamicin or tobramycin because during the slou excretion period relatively inadequate blood and tissue concentrations of the aminoglycoside usually fail to control the septicaemia. In such patients a more effective regimen of treatment is ii newer cephalosporin or cephamycin combined with tlcarcillin. This combination covers nearly all bacteria because ticarcillin is active against organisms which are not killed by cefuroxime or cefamandole- P.seudnn7onrr.sUWU,gi/.l(J.\t/, Sff'?/JtOCOCCLLS ./urca/is, and Buclc~roirkr~. Ticarcillin is not active against Klchsicllu. or Entrrohucrcv hut these organisms are nearly all killed by cefuroxime or cefamandole. Of 100 strains of Sire/>.fur~culis87 were Inhibited b) ticarcillin 32 mg,l and the remaining strains by 64 ing I. After intravenous injection of 6 g tiearcillin blood concentrations were 200400 mgl, and after 3 g 100-200 mg 1. One patient with faecal peritonitis and a high serum creatinine remained febrile for 3 wk during treatment with gentamicin, ampicillin. and Iincomycin. and K / ~ I ~ ; L , / / U was isolated from his abdominal drain. After treatment with cefuroxirne 1500 mg b.d. and ticarcillin 6 g b.d. he rapidly became afebrile and his drainage fluid became sterile. After 2 wk the dose of cefuroxime was reduced io 750 mg b.d. and ticarcillin to 3 g b.d. Such an antibiotic regimen avoids the use of lincomycin or clindamycin. A n old lady with two collections of pus in the abdomen was unsuccessfully treated with oral metro:iidazole and gentamicin or tobramyciii because her high serum creatinine allowed only one dose of the aminoglycoside per da!, After cefoxitin and ticarcillin she rapidly improved and went to surgery. I n 12 paraplegic patients urinary tract infection due to P.~c~~rcionzon~r.s in 12 patients and Provir/cwc.icr sturrrti In 2 patients was cured with ticarcillin 1 g thrice daily. but relapse occurred in 2 patients with abnormal urinary tracts. 111 the urine ofthese patients the peak concentration of ticarcillin was 630-4200 mg:l and the trough concentration was 150-1 500 mgjl. Ticarcillin can produce useful therapeutic concentrations in the cerebrospinal Iluid. A patient with meningitis aftcr a skull fracture failed to respond to chloramphenicol and gentamicin but rapidly became afebrile and clinicall) improved after high doses of ticarcillin and cloxacillin: 7 11 after 6 g ticarcillin intravenously the cerebrospinal fuid still contained 25 mg;l.
SEROTYPES OF PNEUMOCOCCI CAUSING SEVERE INFECTIONS IN AUSTRALIA: CONCORDANCE WITH UNITED STATES PNEUMOCOCCAL VACCINE TYPES
D. HANSMAN M i c r o h i o l o ~Depurtriivnr ,~~ , AcL*Iuirle Children :\ Hospirul A polyvalent pneumococcal polysaccharide vaccine (Pneumovax, Merck, Sharp & Dohnie) i s now licensed l o r ~ise in the United States and Canada. This 14-valent vaccine includes types 1 3. 4. 6-9. 12. 14. 18. 19. 23 and 25. An application to license the vaccine for administration in Australia has been made recently. I t is therefore important to
296
ROYAL COLLEGE OF PATHOLOGISTS OF AUSTRALIA
Pathology (l980), 12. April
know the ‘cover’ of the vaccine relative to the scrotypes of pneumococci causing infections in Australia, and especially in cases of life-threatening infection, namely bacteraemic pneumonia and meningitis. For the 5-yr period, 1974 through 1978. we have analysed the serotypes of pneumococci isolated from blood cultures and specimens of cerebrospinal fluid. from patients in Adelaide, Melbourne and Sydney. In order of frequency. the 10 predominant pneumococcal types encountered among 268 isolates were types 14,9,3 =4, 19,6. I , 18.7 and 23. in that order. Type 14 was predominant amongst isolates from children and type 9 amongst isolates from adults. All of these types were represented in the vaccine, which also includes types 2, 8, 12 and 25. The 14 vaccine types comprised 79.80, of our isolates. Pneumococci of types 2, 12 and 25 were uncommon and together formed only 0.7:,; of the total. Ifa vaccine is to be prepared especially for use in Australia, pneumococcal types 2, I2 and 25 could be omitted and replaced with types 1 I , 22 and 33: cover would then be increased by 9.3‘;” to 89.1‘;” of the types encountered in this study.
ELECTRON MICROSCOPY OF SKIN AND PERIPHERAL BLOOD LYMPHOCYTES IN THE DIAGNOSIS OF EARLY INFANTILE (SANTAVUORI) NEURONAL CEROID LlPOFUSClNOSlS
M . E. HAYNES,R. F. CARTER, J. I. MANSON& E. F. ROBERTSOWDepurtmmrs ofHisroparho1og.l~. Neurologj und Clzoiiicul Palhalog)>.Arleltide Children :r Hospilal The classification and diagnostic histopathological features of the various types of neuronal ceroid lipofuscinosis (Batten’s disease) will be described briefly. An account will then be given of 2 siblings with the early infantile (Santavuori) type in whom the diagnosis was made by electron microscopy of skin biopsies and peripheral blood lymphocytes. In both patients characteristic osmiophilic inclusion bodies were found in various cells in the skin and in lymphocytes. In one patient lymphocyte inclusions were detected before the onset ofany symptoms a s a result of a family study. This indicates the possibility of screening lymphocytes of siblings of affected patients with a view to early detection of the disorder. Antenatal diagnosis by electron microscopy of foetal lymphocytes may also be possible if the inclusions develop early enough in foetal life. As studies to determine this do not appear to have been done, every opportunity should be taken to examine material from foetuses at risk for the discase.
AN AUTOMATIC DATA HANDLING SYSTEM FOR HAEMATOLOGY
J. M. JACKSON. R. E. DAVIS & D. J . NICOL Departnzenf qf Haemarology. Royal Perth Hospital A successful system needs to be simple to operate, attractive to staff at all levels, offer an improvement in the service to users and be economical in reducing the rate of staff expansion. The system described here is operative in a large teaching hospital. The system uses a Control Data Cyber 171 main frame computer which serves several hospitals. This hospital is linked to themain framecomputer via two Digital Equipment Corporation P D P 1 1 concentrators. At the reception desk, test requests are registered using a VDU keyboard. Patient’s identification and location information is automatically available from the medical records patient master index system thereby reducing to a minimum the amount of keyboard entry required. Each sample is given a 3 digit day number and a 2 digit test code; it is then passed to the laboratory. Computer generated worksheets are used to record results of non-automated tests. Results from worksheets are entered through a VDU terminal in batches. A printer produces all blood film labels complete with patient identification and test code. Samples are processed by a Coulter S-Plus which is interfaced with a Hewlett Packard 9835A mini-computer. Results from the Coulter appear on the mini-computer’s screen, they are transferred to tape cartridge and then transmitted to the Cyber in batches. The mini-computer provides a running statistical analysis of results as required for quality control. Differential leucocyte counts are entered through VDU keyboards located next to each of 4 microscopes. Film comments are entered using a simple alpha numeric code. The patient’s cumulative record is available through the VDU. Reports are printed in batches as required using preprinted stationery, all codes being translated to text at the time of printing. Cumulative patient’s records are stored on disc file for 9 mth and are available through any of the department’s VDU’s on demand. When a patient’s file has been inactive for 9 mth it is transferred to microfiche which is stored in the laboratory. Backup of the main rrame computer is provided by a second Cyber. This system is used to process 350-400 samples daily and has the capacity to handle considerably more with only minor modifications. Using this system all results are available on the same day as specimen receipt.